Nitrous oxide is becoming increasingly more popular in the United States as an alternative to the epidural. And for good reason! Nitrous oxide is a very safe, relatively cheap, and effective pain reliever, and we have a lot of evidence on its use. It has been popular for decades in countries that have very good maternal and neonatal health outcomes, such as Canada, Sweden, Finland, and the United Kingdom, and is an important component of quality maternity care.

Nitrous oxide is a gas that is inhaled by mask and is self-administered by the mother. Women who use nitrous oxide during labor may still have an awareness of labor pain. However, many women find it helps them relax and decreases their perception of labor pain. It is a great anxiety-reliever.

Nitrous oxide does not affect the production of oxytocin or the natural progression of labor. It does not increase the probability of other interventions. It also does not affect the baby, and does not increase the need for resuscitation after the birth.

The main side effects caused by nitrous oxide may be slight dizziness, nausea, and sometimes vomiting. But because it is self-administered, a woman may discontinue use of nitrous oxide at any time, and the effects of the gas dissipate within about 5 minutes.

Many birth centers offer the option of delivering your baby in the water, also called water birth. Very few, if any, hospitals allow water birth.

What is a freestanding birth center?A birth center is a freestanding building, not connected to a hospital, where women go to receive maternity care (prenatal and postpartum) and give birth. Birth centers cater to women desiring a natural birth, without medications or medical interventions. Birth centers only care for healthy mothers and babies. High-risk pregnancies are not appropriate for birth center care.

What is the difference between a hospital and a freestanding birth center?

A freestanding birth center is a home-like environment. Many birth centers have luxurious queen beds, dimmable lighting, and a warm and cozy interior. At a birth center, you are free to move around, to eat and drink in labor, and to birth in whatever position feels right to you. Medical equipment is often hidden in cupboards, easily accessible, but out of sight, so it doesn't detract from the environment. Intermittent monitoring of the baby's heart rate is done with a handheld doppler, as opposed to a continuous fetal monitor. Interruptions and medical interventions are kept to a minimum so as not to disturb the laboring person and the natural process of birth.

But not only do birth centers offer a different kind of environment, they offer a completely different kind of care than hospitals.

Monty Python’s The Meaning of Life illustrates the problem birth centers solve in a typically comical and dramatic fashion…

Birth centers, in contrast, provide care according to what’s called the “Midwifery Model of Care.” In the Midwifery Model, care is delivered by midwives, not doctors. Here’s what a family can expect at a birth center:

98.8% of women using a freestanding birth center would recommend it to a friend and/or return to the birth center for a subsequent birth.

If birth centers are so great, why aren’t more women choosing them?

Good question — because there aren’t enough of them.

But why would women desire a birth without medication and/or interventions?

Pregnancy and birth happen by a complex chain of events triggered by hormonal and other physiological changes. Every time we introduce something, like a medication or another type of intervention, we run the risk of upsetting this very fragile biological process. When the process of labor is interrupted, it causes problems which necessitate other interventions to stay on track and keep everyone safe. This phenomenon is called the “Cascade of Interventions.” It can be thought of like a snowball — one intervention leads to another, and then another, and another. The ultimate intervention, where the baby is removed by surgery to the abdomen, is called a Cesarean Section. In the US, 1 in 3 women is having a C-section. This is SO HIGH! And it has grown considerably over the last several years.

“Like any other major surgery, c-sections can have complications, like damage to other organs, internal bleeding, blood clots or infection. Recovery after a c-section is typically longer than that of a vaginal birth. Moms who have c-sections may experience as much as six weeks of post-operation pain and bleeding, versus bleeding and vaginal discharge for two to four weeks after a vaginal birth. Finally, women who have a c-section for their first baby will face risks for subsequent pregnancies, like a higher chance of the placenta implanting or growing abnormally, or uterine rupture along the site of the scar.” Huffington Post

Birth centers specialize in unmedicated birth. They educate women and their families prenatally about what to expect in labor and how to cope with the intensity of birth. Most women do just fine. I have heard women say that labor was not nearly as painful as expected, and that having a spider bite incised was far more painful!

That is not everyone’s experience, however. So birth centers do offer tools like massage, hydrotherapy (water is very relaxing in labor), TENS units (electro-stimulation), and other natural measures to help women cope.

That being said, there are some pain medications that pose minimal risk and can be used safely in a birth center. Those medications are nitrous oxide (laughing gas) and some types of narcotics.

How much does birth center care cost?

Not only do birth centers provide more personalized, attentive care with fewer interventions, but they are also far less expensive than hospitals. The New York Times did a great job of summing up the incredible costs of having a baby in their 2013 article, American Way of Birth, Costliest in the World. Here’s an excerpt:

“When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. “It was unreal,” Ms. Martin said. “I was like, How could you not know this? You’re a hospital.”

[…] Add up the bills, and the total is startling. “We’ve created incentives that encourage more expensive care, rather than care that is good for the mother,” said Maureen Corry, the executive director of Childbirth Connection.”

By comparison, cost of care in a birth center is usually a flat fee and varies by cost of living in that part of the country. Ranges are from about $4000 in Austin, TX to $9000 in the San Francisco Bay Area.

Does health insurance cover birth center care?

YES! Most PPO plans cover some portion of birth center and midwifery care. The amount varies considerably by plan, but many plans cover between 1/3 to the full amount of the fees.

Are birth centers licensed?

In California, licensing of birth centers is optional, and there are a number of reasons a birth center might choose to forego licensure. All midwives, however, are licensed. Licensed midwives are licensed by the Medical Board of California. Many other states also have legislation for licensing midwives and birth centers.

Is birth center care safe?

Yes, it is. Midwives that work in birth centers are fully licensed and have followed a course of study that prepares them to safely care for families in a birth center setting. Birth centers stock a variety of tools to handle potential emergencies, including medications to stop bleeding, resuscitation equipment for both the baby and the mother, and oxygen. All staff are trained in Neonatal Resuscitation, CPR and Advanced Life Support in Obstetrics. Statistics for nearly 17,000 out-of-hospital births and their outcomes can be found here.

Do birth centers carry malpractice insurance?

Yes, birth centers and the midwives who work in them are required to carry malpractice insurance.

Where can I learn more about the maternity care industry in the US?

Ricki Lake did a fantastic documentary called The Business of Being Born that gives an enlightening look at the issues surrounding maternity care in the US. Here’s the trailer…

In January of this year, the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) released a document that is likely to have a substantial impact on the United States maternal health care system. In the document, titled “Levels of Maternity Care,” they call for an “integrated, regionalized framework” for maternal care. This framework includes a striated classification system for levels of maternal care according to risk status. The goal of the new system is for women to receive care that is appropriate to their level of need, including moving women up to more specialized regional hospitals if they become higher-risk, thereby reducing maternal mortality and morbidity.

ACOG is a professional association of physicians specializing in obstetrics and gynecology. It has a membership of 55,000 and represents 90% of US board-certified obstetrician-gynecologists. Because the vast majority of women in the US currently seek out an OBGYN for their care during pregnancy, the standards upheld by ACOG basically set the standards for maternity care in the US. SMFM is a non-profit devoted to improving perinatal care (care around the time of birth) with a membership of about 2000.

What makes the ACOG/SMFM document really significant for out-of-hospital birth is that in their vision for the future, healthy, low-risk women are receiving care from licensed midwives and giving birth in freestanding birth centers. Until last month, ACOG had summarily written off certified professional midwives (CPM) and licensed midwives (LM) and refused to acknowledge them as part of the maternity care system. However, in the new proposed framework, birth centers comprise the lowest risk level of care, and primary care providers at this level include “certified nurse–midwives (CNMs), certified midwives, certified professional midwives, and licensed midwives who are legally recognized to practice within the jurisdiction of the birth center; family physicians; and obstetrician–gynecologists.” This is a big position change for ACOG. But why?

The reasons for these poor outcomes are complex - they are organizational, financial, cultural, economic, linguistic and technological - and we don’t have space to go into all of them here. The ACOG/SMFM framework attempts to address some parts of the problem. And that’s where midwifery comes into the equation. Midwifery care is “high-touch, low-tech” care, meaning it is very personalized, without an over-reliance on technology and testing, which can be costly. Women who receive care from a midwife also have drastically lower rates of invasive procedures like c-section or episiotomy. And guess what…midwifery care is far less expensive. Like ridiculously cheaper. In the US, the average cost of a vaginal birth is about $30,000. A c-section: $50,000. A midwife out-of-hospital? In my experience, anywhere from $2900 in Texas where the cost of living is low to $7000 in San Francisco where the cost of living is very high. So even the most expensive midwife, compared to an average hospital birth, is still less than one quarter of the price!

ACOG's position change also comes on the heels of some pretty widespread pro-midwife, pro-out-of-hospital-birth media coverage from across the pond. The UK’s National Institute for Health and Care Excellence (NICE) released guidelines on December 3, 2014 encouraging low-risk British women to have their babies with midwives. According to Professor Mark Baker, NICE’s clinical practice director: “Most women are healthy and have straightforward pregnancies and births. Over the years, evidence has emerged which shows that, for this group of women, giving birth in a midwife-led unit instead of a traditional labour ward is a safe option. Research also shows that a home birth is generally safer than hospital for pregnant women at low risk of complications who have given birth before. Where and how a woman gives birth to her baby can be hugely important to her. Although women with complicated pregnancies will still need a doctor, there is no reason why women at low risk of complications during labour should not have their baby in an environment in which they feel most comfortable. Our updated guideline will encourage greater choice in these decisions and ensure the best outcomes for both mother and baby.”

This is not the first time ACOG has ceded ground to out-of-hospital birth. In 2006, ACOG released a statement insisting that the hospital “is the safest setting for labor, delivery, and the immediate postpartum period.” It concluded that ACOG “strongly opposed out-of-hospital births” and “does not support programs or individuals that advocate for or who provide out-of-hospital births.” In 2007, after quite a bit of outcry from their own membership and from consumer groups, ACOG changed their statement to acknowledge the safety of birth in out-of-hospital birth centers that meet accreditation standards. ACOG continues to oppose home birth, but does not provide any evidence for doing so.

Whatever the reason for ACOG’s most recent change of heart, this call for a more integrated, multilevel maternity care system is a positive step in the right direction. The only way to provide better care for moms and babies is if providers at all levels of care communicate and work together within a structured system. And it's obvious that women do and will continue to choose licensed midwives and out-of-hospital birth no matter what ACOG says or does. So it’s about time we all get on the same boat. I’d say we’ve got some big changes coming, and frankly, they look good.